Lip Tie – What’s it all about?

Sarah Oakley BA (Hons) RGN, RHV, IBCLC

Independent Health Visitor, Lactation Consultant and Tongue-tie
Practitioner

I work as an independent lactation Supporters, Breastfeeding

consultant and tongue-tie Counsellors and trainees. But ABM
practitioner and have a background volunteers are not the only ones
in health visiting and practice nursing.
mystified by this issue. It is a subject
I have been an ABM Breastfeeding I write and talk about almost daily
Counsellor since 2004 and am Chair due to the enquiries I receive from
of the Association of Tongue-tie parents and healthcare professionals,
Practitioners. both directly to me and via the
Association of Tongue-tie
I offered to write this article after Practitioners website. It is a subject
some discussions on the ‘ABM that on two occasions has destroyed
Trained and Training’ Facebook group my relationship with families who
revealed a lot of confusion and have believed that I have been
conflicting information on the subject neglectful in my duties by not
of ‘lip tie’ amongst ABM Mother diagnosing and treating their baby for

1
lip tie, whilst I divided the tongue-tie, has come up with a classification
after taking advice from groups on system and describes it as follows:
Facebook, Dr Google, etc.
“The upper lip can be classified by
So what is a ‘lip tie’? assessing the inner lip’s mucosal
attachment. When the lip attachment
This is our first major problem. The inserts into the zone where the two
presence of a frenum (a tethering) upper front teeth will emerge and
stretching from the upper gum to extends beyond the maxillary alveolar
behind the upper lip in the midline is ridge into the palatal area, the lip-tie is
normal anatomy. classified as a Class IV lip-tie, inserting
into the zone just forward of the palatal
According to Mohan et al (2014) “a area between the area of the future
normal frenum attaches apically to the two front teeth is a Class III lip-tie, the
free gingival margin so as not to exert a insertion zone into the area of the free
pull on the zone of the attached gingiva and attached gingival is identified as a
and usually terminating at the Class II lip-tie and if the attachment is
mucogingival junction. However, its level above this area, it is identified as Class
may vary from the height of vestibule to I.”
the crest of the alveolar ridge and even
to the incisal papilla area in the anterior For images of lip ties and how they
maxilla”. look within this classification system
google ‘Kotlow Lip Tie
Or put more simply by Townsend et Classification’.
al (2013). “The median maxillary labial
frenum (MMLF) is a fold of mucous Kotlow’s diagnosis of a lip tie is
membrane found on the underside of based on where the frenum inserts
the center of the upper lip that or attaches. Note that according to
connects to the midline of the attached him all types of maxillary labial
gingiva between the central incisors. It frenums are ‘lip ties’. There is no
adapts to any of the normal movements reference to what is normal.
of the lip. As the primary teeth erupt, However, according to Mohan et al
the height in the alveolar structures (2014) (and others including Placek
increases normally and the attachment et al, 1974) the level of attachment
of the frenum moves superiorly with the in a normal frenum may vary “from
maxillary alveolar crest.” the height of vestibule to the crest of
the alveolar ridge and even to the
So when is a maxillary labial frenum incisal papilla area in the anterior
abnormal and considered restricted? maxilla”.
Larry Kotlow, a dentist in the USA,

2
Baby with top lip in neutral position
maxillary lip should be free to enable
Kotlow's diagnostic classifications the infant’s lip to extend upward to
rely solely on appearance. But what maximize the infant’s attachment onto
about function? When assessing the areola, rather than onto just the
tongue-ties there is a consensus that nipple. When the upper lip’s inner
it is all about function. “A mucosa is attached to the alveolar ridge
determination of tongue-tie should be of the maxillary arch and the lip is
made first on function and second on unable to fully flange upward, it also can
appearance. The now-substantial body also become a factor in creating a
of available research shows that shallow latch which then can allow the
functional criteria supersede appearance passage of excess air to be introduced
criterial” (Hazelbaker, 2010, p151). into the infant’s belly resulting in
aerophasia and reflux”.
Whilst we have assessment tools
that look at function for tongue-tie In one of his many online blogs
the same does not exist for lip tie. written on 6 March 2014 Bobby
Ghaheri, an ENT Surgeon from the
Kotlow (2015) provides this as a USA who treats lip ties and tongue-
rationale for treating lip tie “the tie, made this acknowledgement. “It is

3
Baby with top lip flanged
important to know that there are no
peer-reviewed studies showing the
efficacy of dividing an ULT when
breastfeeding is impacted. While there
are qualitative objective measures that
seek to grade the severity of
breastfeeding dysfunction with respect
to a tongue-tie, no such measures exist
for an ULT”.
In a Facebook exchange with Bobby
and some of his colleagues I asked
how they decide a lip requires
division. The responses were that it
is based on the presence of tension
and a general acknowledgment that
they were probably all applying
different criteria. This was reflected
in the fact that they all reported
varying numbers of babies presenting
with tongue-ties who also require lip
tie division. Anything from 20% up to
almost all babies with tongue-tie
were also being treated for lip tie. In
his blog of 8 October 2014 Bobby
wrote this, “degree of restriction can
be determined by feeling the lip and
trying to elevate it, mimicking the
flanging motion needed on the breast.
Alternatively, an IBCLC (international
board certified lactation consultant) can
evaluate what the lip is doing on the
breast”.
So both Larry Kotlow and Bobby
Ghaheri mention the need for the
4
 neutral to slightly everted on the breast
and should be relatively immobile during
sucking.’ She goes on to say ‘an overly
flanged upper lip is a sign of shallow
attachment or overuse of the lip to
compensate for tongue immobility”.

This could explain why some parents

and healthcare professionals claim to
have seen improvement in
breastfeeding after lip tie division.
The added ability to fully flange the
top lip will allow a baby to
compensate for continued poor
positioning or tongue function issues.
But of course this is treating a
symptom and not the underlying
cause. Improving positioning, tongue
–tie division, tongue exercises and
Sarah Oakley
suck training to promote effective
tongue mobility would be more
top lip to flange in order to achieve a appropriate.
deep and effective latch. Is this true?
This is the opinion of a dentist and an Alison Hazelbaker in her blog
ENT surgeon. So what do the Modern Myths about Tongue-tie:
experts in breastfeeding - lactation The Unnecessary Controversy
consultants - have to say about the Continues wrote this:
role of the lips? “Let’s look at the assertion that a tight,
prominent upper lip frenum causes
Catherine Watson Genna IBCLC in breastfeeding problems more closely.
her latest 2017 edition of Supporting We can use anatomy, physiology and
Sucking Skills in Breastfeeding Infants development as our guide. First: the
says, “lips are gently applied to the upper gumline changes with growth. A
breast with the lower lip flanged frenum that appears to be restricted in
completely outward and the upper early infancy may substantially change
lip neutral to slightly flanged” (p 28). as the baby grows. Second:
She goes on to quote an article by breastfeeding does not require a lip
Kay Hoover IBCLC from 1996 on flange, merely lip eversion. Third: the
page 37. “The nasolabial crease should assertion that dental caries is caused by
remain soft, and the upper lip should be an upper lip tie begs to be proven.

5
Breastmilk does not pool in the mouth.
The position of the nipple in the mouth
and the manner in which that milk is
moved into the pharynx for the swallow
won’t allow it. Both the peristaltic action
of the tongue and the pressure
differential created by tongue
movements quickly push/pull the milk to
its ultimate destination. Fourth: the lips
follow the tongue, if the tongue retracts,
the lips move inward toward the
gumline and when the tongue everts,
the lips also evert. This is a
developmental reflex that remains
active throughout life. Anyone who has
ever French-kissed can assert the truth
of this. Tongue position plays such a
keen role in the positioning of the lips
that many types of acquired structural
issues, like torticollis, can cause the
tongue to retract thereby pulling in the
lips. In my experience, this can be
mistaken for what the theorists call an
upper lip tie”.
What about the treatment of
lip tie?
Whilst in the USA, Canada and
Australia a growing number of babies
are having lip tie division alongside
tongue-tie division this is not the
case in the UK. The NHS generally
does not offer lip tie division to
babies for feeding issues. Some lip
ties are treated on the NHS at
around the age of 11 or 12 if there
are concerns about a diastema (gap
in the teeth). But as explained at the
beginning of this article “as the
primary teeth erupt, the height in the
alveolar structures increases normally
and the attachment of the frenum
moves superiorly with the maxillary
alveolar crest”. (Townsend et al
2013). So many of the babies with
the type 2,3 and 4 lip ties on
Kotlow’s classification system will
not need lip tie division as they get
older anyway.
In the UK the Association of Tongue
-tie Practitioners has produced this
statement on lip tie on their website
www.tongue-tie.org.uk which
explains concisely the UK position:
“Currently there is no published
evidence supporting a link between
breastfeeding issues and lip tie.
“The National Institute for Health and
Care Excellence (NICE) have not issued
any guidance on this issue and therefore
training is not available in the UK in lip
tie division for practitioners.
“This situation may change in the future
if new research and evidence influences
best practice guidelines. Currently
nurse/midwife tongue-tie practitioners
working in the UK cannot offer lip tie
division as the Nursing and Midwifery
Council's Code of Conduct states that
nurses, midwives and health visitors
must 'deliver care based on the best
available evidence or best practice' and
ensure any advice given is evidence
based if suggesting healthcare products
6
or services. pressing on the wound to break
down adhesions is advised.
“The Code also requires that nurses and
midwives recognise and work within the Not all doctors and dentists are
limits of their competence. On the rareconvinced that the procedure is safe
occasions that lip ties are divided by in babies either. Unlike tongue-tie
surgeons in the NHS it is usually done in
division which is a long established
relation to concerns about dental issues,
procedure in babies dating back 400
not breastfeeding. If you have concernsyears, lip tie division is a much more
about lip ties we suggest you discuss this
recently developed intervention.
with your dentist”. Angus Cameron, Associate Professor
of Dentistry in Australia explained to
The only treatment option for babies me, in a telephone conversation in
is a private dentist in London who June 2015, that he had come across
offers laser division. But this is cases where the adult teeth inside
expensive. the gum had been damaged during
the procedure and where scar tissue
What does lip tie treatment formation had created a permanent
involve? diastema. He has this information on
his website (http://
This website provides a description sydneytonguetie.com.au/):
of how a lip tie may be treated either
with scissors or laser “There is currently NO evidence that a
www.fauquierent.net/upperliptie.htm thick or short labial frenum has any
negative influence on breast-feeding.
Local anaesthetic is used and the The mere presence of a labial frenum
labial frenum may be clamped to does NOT indicate a need for surgery.
crush the blood vessels before Releasing a upper labial frenum is a
division. The maxillary labial frenum traumatic procedure that may also lead
is much more sensitive and more to more dental problems later including
vascular than a lingual frenum the persistance of an anterior diastema
(tongue-tie) so the risk of pain and (gap between the front teeth) that is
bleeding is greater. There is also a difficult to close orthodontically”.
high risk of the lip tie to heal back
together again because the lip is What do we tell parents?
relatively immobile, compared to the
tongue, and of course the lip rests As breastfeeding supporters and
against the gum constantly. So wound specialists we need to explain to
management involving massaging or parents first and foremost how a
baby latches effectively to the breast,

7
the role of the lip and how to References
achieve a good latch. We need to
acknowledge that there is a lot of Mohan R, Soni PK, Krishna MK,
information on this issue on the Gundappa M. Proposed classification
internet but that there are large gaps of medial maxillary labial frenum
within this information and experts based on morphology. Dent
are divided. With what we know Hypotheses 2014;5:16-20.
about how babies latch if lip ties do
affect feeding it will only be in a very
Townsend JA, Brannon RB,
tiny number of babies. However, Cheramie T, Hagan J, Prevalence and
even those practicing lip tie division
variations of the median maxillary
acknowledge the lack of evidence labial frenum in children,
that it impacts on feeding and the adolescents, and adults in a diverse
need for an evidence based tool for population General Dentistry March/
assessment. April 2013
Kotlow L TOTS–Tethered Oral
Regardless of what any of us want to Tissues The Assessment and
believe, options for treatment are Diagnosis of the Tongue and Upper
limited in the UK and safety and Lip Ties in Breastfeeding General
efficacy of treatment has not been Dentistry March 2015
evaluated. So, our focus needs to be
on supporting mothers and babies Catherine Watson Genna
with our breastfeeding skills to Supporting Sucking Skills in
understand and overcome the Breastfeeding Infants 2017.
challenges they face and not to
encourage them to pursue the idea http://www.kiddsteeth.com/
that by simply cutting yet another
piece of membrane in the mouth all http://www.alisonhazelbaker.com/
of their issues will be solved. blog/2015/9/1/modern-myths-about-
tongue-tie-the-unnecessary-
controversy-continues
http://www.drghaheri.com/